Humalog insulin alert - Hqsc.govt.nz

LOGO
Medication Alert
HUMALOG ® INSULIN Preparations
Alert 10 April 2010
For the attention of:
For action by:
For information to:
Purpose of this alert
All prescribers, pharmacists and nurses
Primary Care Facilitators, PHO Clinical Leaders – for dissemination to all GPs in
your PHO, DHB Medicines Advisory Committees, Medication Safety Pharmacists,
Quality Managers
College of GPs, Pharmaceutical Society of NZ, Pharmacy Council, College of
Nurses, Schools of Medicine, Pharmacy and Nursing, NZ Hospital Pharmacists’
Association, New Zealand Nurses Organisation
To highlight the risk of errors caused by the confusion that can occur during the prescribing, dispensing
and administration of the following insulin products: Humalog ®
Humalog Mix25 ®
Humalog Mix50 ®
Background to this Safe Use of Medicines Alert
• There is the potential for serious harm if a patient receives rapid acting plain Humalog ® when a mixed
rapid/intermediate acting Humalog Mix ® product is intended, especially for those on high doses
• Humalog ® has been available in New Zealand for a number of years, but Humalog Mix 25 ® and
Humalog Mix 50 ® have been introduced recently
• One DHB has reports of six prescribing and two administration incidents in a 10 week period involving
confusion between Humalog ® and Humalog Mix ® products
• Dispensing errors have been reported where Humalog ® has been dispensed instead of Humalog
Mix25 ® or Humalog Mix50 ®
Recommended Action
• Prescribe insulin using the FULL BRAND name; prescribe units in FULL
• Highlight this potential for error to as many healthcare professionals as possible -
distribute this Alert widely throughout your DHB
• Highlight the potential for error to patients prescribed Humalog ® or Humalog Mix ®
• When using electronic prescribing or dispensing systems cross check you have
selected the correct item from the drop-down menu – remember there are three
Humalog products available
• Check what type of insulin the patient should be on e.g. rapid acting or a mixture of
rapid and intermediate acting insulin and prescribe the insulin using the FULL BRAND
name
• Confirm with the patient (or carer) that the correct insulin is being prescribed,
dispensed or administered
For further action by DHBNZ Safe and Quality Use of Medicines Group
1. The group will work with Patient Management Systems and dispensary systems to introduce alerts to
highlight the different formulations

HUMALOG ® Product Descriptions
Brand Name Humalog ® Humalog Mix25 ® Humalog Mix50 ®
Type of insulin RAPID ACTING INTERMEDIATE-ACTING
PREMIXED INSULIN
LISPRO
INTERMEDIATE- ACTING
PREMIXED INSULIN
LISPRO
Appearance CLEAR CLOUDY CLOUDY
Generic Name
insulin lispro Rbe
(rapid acting)
25% insulin lispro
(rapid acting)
50% insulin lispro
(rapid acting)
PLUS
PLUS
75% insulin lispro protamine
suspension Rbe
(intermediate acting )
50% insulin lispro protamine
suspension Rbe
(intermediate acting)
Presentation
10ml vials
3ml cartridges
3mL cartridges
3 mL cartridges
Onset of action 0 to 15 minutes 0 to 15 minutes 0 to 15 minutes
Peak 1 hour 1 hour 2 hours
Duration 2 to 5 hours 16 to 18 hours 16 to 18 hours
CASE STUDY
A hospital inpatient was commenced on Humalog Mix25® with a dose of 20 units each morning, and 24
units each evening.
The prescription was faxed to the hospital Pharmacy; Humalog Mix25® was dispensed with an
individualised patient label, and stored in the ward fridge. A vial of Humalog® was already in the ward
fridge.
24 units of Humalog® were administered in the evening and another 20 units of Humalog® the following
morning. The patient had a hypoglycaemic episode two hours after the first dose, and had hyperglycaemia
the following morning prior to receiving the second dose of Humalog®, resulting in a prolonged hospital
stay to stabilise the blood sugar level.
For an electronic version of this alert download from the website, www.safeuseofmedicines.co.nz or
contact Beth Loe, Beth.Loe@waitematadhb.govt.nz
These recommendations are based on a review of the currently available information in order to assist practitioners. The recommendations are general guidelines only
and are not intended to be a substitute for individual clinical decision making in specific cases
If you require any further information or wish to provide feedback
on this alert, please go to www.safeuseofmedicines.co.nz